Empty Bladder Research Articles

Cerebellar functional connectivity relates to lower urinary tract function: A 7 Tesla study.

The objective of this study is to explore the functional connectivity (FC) of the cerebellum during the storage phase of micturition, through detecting spontaneous blood-oxygen-level dependent signal between the cerebellum and different brain regions using a high-resolution 7 Tesla magnetic resonance imaging (MRI) scanner. We recruited healthy individuals with no reported history of neurological disease or lower urinary tract (LUT) symptoms. Participants were asked to drink 500 mL of water and then empty their bladders before entering the MRI scanner. They underwent a T1-weighted anatomical scan, followed by an initial (8 min) empty bladder resting state functional MRI (rs-fMRI) acquisition. Once subjects felt the desire to void, a second rs-fMRI scan was obtained, this time with a full bladder state. We established a priori cerebellar regions of interest from the literature to perform seed-to-voxel analysis using nonparametric statistics based on the Threshold Free Cluster Enhancement method and utilized a voxel threshold of p < 0.05. Twenty individuals (10 male and 10 female) with a median age of 25 years (IQR [3.5]) participated in the study. We placed 31 different 4-mm spherical seeds throughout the cerebellum and assessed their FC with the remainder of the brain. Three of these (left cerebellar tonsil, right posterolateral lobe, right posterior lobe) showed significant differences in connectivity when comparing scans conducted with a full bladder to those with an empty bladder. Additionally, we observed sex differences in FC, with connectivity being higher in women during the empty bladder condition. Our initial findings reveal, for the first time, that the connectivity of the cerebellar network is modulated by bladder filling and is associated with LUT function. Unraveling the cerebellum's role in bladder function lays the foundation for a more comprehensive understanding of urinary pathologies affecting this area.

Why are continent catheterizable channels continent? A stomal pressure profilometry feasibility study.

A continent catheterizable channel (CCC) may be a solution for patients with impaired bladder emptying and difficult transurethral access. Leakage of the CCC is a common complication. To prevent leakage, the pressure in the CCC has to be higher than the reservoir (bladder/pouch) pressure in at least one location. It has not been clearly defined through which mechanism(s) the CCC achieves continence. In this feasibility study, we measured the CCC pressure profile in adult patients with various types of CCC's with and without stomal leakage. Adult patients with a CCC on a (augmented) bladder or pouch who underwent a urodynamic investigation between January and March 2023 were included. Next to the standard urodynamic investigation, a continuous stomal pressure measurement (CSP) and stomal pressure profilometry with empty bladder (SPP-1) and with filled bladder (SPP-2) of the CCC were performed. A total of 17 patients were included. It was technically possible to perform SPP-1 and SPP-2 in all patients, and to measure the CSP in 16/17 patients. The median maximum stomal pressures in SPP-1 and SPP-2 were 112 (interquartile range [IQR], 76-140) cmH2O and 120 (IQR, 92-140) cmH2O, respectively. Nine patients had stomal leakage during the urodynamic investigation. In five patients, the detrusor leak point pressure (dLPP) was low (<20 cmH2O). A pressure peak at the beginning of SPP-2 was absent in all patients with stomal leakage at low dLPP. SPP and CSP measurement in CCCs are feasible. We found differences in SPP-2 between patients with and without leakage at low dLPP, indicative of a role of the intravesical tunnel in continence or high dLPP. The results of this study may improve our understanding of the physiology and dynamics of CCCs as well as the management of CCC-related complications.

Full bladder, empty rectum? Revisiting aparadigm in the era of adaptive radiotherapy.

Many patients find it challenging to comply with instructions regarding rectum and bladder filling during pelvic radiotherapy. With the implementation of online adaptive radiotherapy, the reproducibility of organ volumes is no longer aprerequisite. This study aims to analyze the sparing of the bladder and the posterior rectum wall (PRW) in conditions of full versus empty bladder and rectum. 280 fractions from 14 patients with prostate cancer who underwent adaptive radiotherapy using the Varian Ethos system were analyzed post-hoc. Various metrics for the bladder and PRW were correlated with respect to organ volume. Our analysis quantitatively confirms the advantage of afull bladder during radiotherapy, as metrics V48Gy and V40Gy significantly inversely correlate with bladder filling for each patient individually. While bladder volume did not show agradual decrease over the course of radiotherapy, it was observed to be higher during planning CT scans compared to treatment sessions. Afull rectum condition either significantly improved (in 2 out of 7 patients) or at least did not impair (in 5 out of 7 patients) PRW sparing, as represented by the V30Gy metric, when patients were compared individually. The average V30Gy across all patients demonstrated asignificant improvement in PRW sparing for the full rectum condition, with a[Formula: see text]-value of 0.039. Despite the implementation of adaptive therapy, maintaining ahigh bladder filling remains important. However, the recommendation for rectum filling can be abandoned, as reproducibility is not critical for adaptive radiotherapy and no dosimetric advantage per se is associated with an empty rectum. Patients may even be encouraged not to void their bowels shortly before treatment, as long as this is tolerated over the treatment session.

Impact of Sonographer Experience, Insonation Angle, and Bladder Filling on Uterine Artery Doppler Measurements in the First Trimester of Pregnancy.

To investigate the influence of different measurement conditions and ultrasound training level on uterine artery pulsatility index (UtA-PI) measurements as required for combined first trimester preeclampsia (PE) screening. This was a prospective study of consecutive patients with singleton pregnancies presenting for an ultrasound examination between 11 and 14 weeks' gestation. UtA-PI measurements were conducted by residents in training and repeated by experienced sonographers thereafter. UtA-PI measurements were conducted under different examination conditions. First, the trainee sonographers performed transabdominal sagittal and transverse UtA-PI measurements without bladder filling. These measurements were then repeated by the expert sonographers. Additionally, the expert sonographers also performed transvaginal UtA-PI measurements and transabdominal measurements with bladder filling. Statistical analysis was conducted with the statistical software R and included descriptive statistics as well as 2-sided paired t tests. A total of 100 women were included in the study. Mean age was 31.7 ± 4.92 years and mean gestational week was 12.5 ± 0.53 weeks. A total of 56% were nulliparous and 44% were parous. UtA-PI was significantly lower if performed by a sonographer in training versus an experienced sonographer (P = .031). No significant difference was observed in comparing transverse and sagittal techniques (P = .241). There was also no significant difference in transabominal versus transvaginal measurements (P = .806) and with an empty versus full bladder (P = .444). Experience of sonographer has a significant impact on UtA-PI. Supervised onsite training is necessary to improve reliability and consistency of UtA-PI measurements and make PE screening reliable for implementation in a universal screening setting.

Three-Dimensional Conformal Radiotherapy Versus Image-Guided Intensity Modulated External Beam Radiotherapy in Locally Advanced Cervical Cancer: A Phase III Randomized Control Study

AimsThe standard treatment of locally advanced cervical carcinoma is radical chemoradiation followed by brachytherapy which has improved survival. Hence, a major concern is our attempt to reduce the incidence of acute and late toxicities. IMRT has been shown to reduce toxicities. In this study, we have compared 3DCRT with IG-IMRT using patient-specific margins to evaluate tumor control as well as OAR-related toxicities. Materials and MethodsThis was a single institution prospective phase III randomised control study including patients of squamous cell carcinoma of cervix (stage II–IIIB, FIGO 2009) without pelvic lymph node involvement. All patients were simulated using intermediate bladder filling protocol and those in the IG-IMRT arm, underwent additional scans with full and empty bladder to assess the range of internal motion and generate individualised ITV margin. EBRT dose of 46Gy/23#/4.5 weeks was delivered with weekly concurrent cisplatin followed by brachytherapy. All toxicities during EBRT and till 3 months post brachytherapy were considered acute toxicity. Post-treatment, patients were followed up every 2 months for first 2 years and then once every 6 months. Disease-related outcomes were assessed with clinical examination and symptom-directed imaging. ResultsTwo hundred patients were screened for inclusion and of them, 89 patients in 3DCRT and 84 patients in IG-IMRT arms were considered for final analysis. The baseline characteristics were comparable in both arms, majority of patients in both arms having stage II disease. For OARs, all dosimetric parameters were significantly better in the IG-IMRT arm. Acute radiation induced toxicities (dermatitis, genito-urinary and gastrointestinal toxicities) were significantly less in the IG-IMRT arm. The local, pelvic, and distant control were comparable in both arms. ConclusionBased on our experience, the use of IG-IMRT with patient-specific ITV margins results in reduction in acute OAR toxicities in patients without compromising on tumor control.

Brain Responses Difference between Sexes for Strong Desire to Void: A Functional Magnetic Resonance Imaging Study in Adults Based on Graph Theory.

Background: The alternations of brain responses to a strong desire to void were unclear, and the gender differences under the strong desire to void remain controversial. The present study aims to identify the functional brain network's topologic property changes evoked by a strong desire to void in healthy male and female adults with synchronous urodynamics using a graph theory analysis. Methods: The bladders of eleven healthy males and eleven females were filled via a catheter using a specific infusion and withdrawal pattern. A resting-state functional magnetic resonance imaging (fMRI) was performed on the enrolled subjects, scanning under both the empty bladder and strong desire to void states. An automated anatomical labeling (AAL) atlas was used to identify the ninety cortical and subcortical regions. Pearson's correlation calculations were performed to establish a brain connection matrix. A paired t-test (p < 0.05) and Bonferroni correction were applied to identify the significant statistical differences in topological properties between the two states, including small-world network property parameters [gamma (γ) and lambda (λ)], characteristic path length (Lp), clustering coefficient (Cp), global efficiency (Eglob), local efficiency (Eloc), and regional nodal efficiency (Enodal). Results: The final data suggested that females and males had different brain response patterns to a strong desire to void, compared with an empty bladder state. Conclusions: More brain regions involving emotion, cognition, and social work were active in females, and males might obtain a better urinary continence via a compensatory mechanism.

Human HPSE2 gene transfer ameliorates bladder pathophysiology in a mutant mouse model of urofacial syndrome.

Rare early-onset lower urinary tract disorders include defects of functional maturation of the bladder. Current treatments do not target the primary pathobiology of these diseases. Some have a monogenic basis, such as urofacial, or Ochoa, syndrome (UFS). Here, the bladder does not empty fully because of incomplete relaxation of its outflow tract, and subsequent urosepsis can cause kidney failure. UFS is associated with biallelic variants of HPSE2, encoding heparanase-2. This protein is detected in pelvic ganglia, autonomic relay stations that innervate the bladder and control voiding. Bladder outflow tracts of Hpse2 mutant mice display impaired neurogenic relaxation. We hypothesized that HPSE2 gene transfer soon after birth would ameliorate this defect and explored an adeno-associated viral (AAV) vector-based approach. AAV9/HPSE2, carrying human HPSE2 driven by CAG, was administered intravenously into neonatal mice. In the third postnatal week, transgene transduction and expression were sought, and ex vivo myography was undertaken to measure bladder function. In mice administered AAV9/HPSE2, the viral genome was detected in pelvic ganglia. Human HPSE2 was expressed and heparanase-2 became detectable in pelvic ganglia of treated mutant mice. On autopsy, wild-type mice had empty bladders, whereas bladders were uniformly distended in mutant mice, a defect ameliorated by AAV9/HPSE2 treatment. Therapeutically, AAV9/HPSE2 significantly ameliorated impaired neurogenic relaxation of Hpse2 mutant bladder outflow tracts. Impaired neurogenic contractility of mutant detrusor smooth muscle was also significantly improved. These results constitute first steps towards curing UFS, a clinically devastating genetic disease featuring a bladder autonomic neuropathy.

Oligohydramnios and an empty bladder with normal renal morphology: Renal tubular dysgenesis is an important consideration in the prenatal setting.

SynopsisOur study indicates that if oligohydramnios is noted but with an unremarkable fetal renal scan, autosomal recessive renal tubular dysgenesis should be enlisted as a main differential diagnosis.

Assessment of the Severity of Urinary Incontinence Among Elderly Women

Background: The International Continence Society (ICS) defines urinary incontinence (UI) as the complaint of any involuntary leakage of urine. It is a distressing and debilitating condition that is becoming more prevalent as our population ages. Pathophysiology of urinary incontinence during menopause the ovaries stop producing considerable quantities of estrogen; hence the symptoms and problems associated with estrogen deficiency occur gradually. Among the changes is reduction in the integrity of the pelvic floor, changes in the rate of different types of collagens and the preferential atrophy of type II muscle fibers, atrophy of urinary-genital tract which may be associated with problems such as urinary urgency, urinary frequency, nocturia, stress incontinence, urge incontinence, burning upon urination and an increased prevalence of urinary tract infections. Aim of the study: The study aimed to assess severity of urinary incontinence among elderly women. Design: A descriptive study design was utilized in this study. Sample: A purposive sample of 100 women diagnosed with stress urinary incontinence. Setting: gynecological and urological outpatient clinics Beni-Suef university hospital. Tools: (1) A structured interviewing questionnaire sheet was developed by the researcher in the Arabic language. It was containing of two parts; (1) personal characteristics data of the study women such, (2) urinary incontinence history; (2) The International Consultation on Incontinence Modular Questionnaire ICIQ-SF. Results: The mean weight of the studied sample was 82.680±11.8815, mean height was 160.420±2.8610, and mean of BMI was 32.1224±4.47973. It indicates that 42% of the study sample their frequency of urination was every 3-6 hours, 75% of them had a completely empty bladder after voiding, 37% did not used sanitary towel for urine leakage. Conclusion: Based on the results of the study; It can be concluded that most of elderly women suffer from sever urinary incontinence. Recommendations: Replication of the present study under different circumstances (sampling and setting) is recommended to validate its results.

Comparison between using an Automatic Uterine Massage Machine and manual uterine massage on postpartum blood loss within two hours after delivery at labour room, Phramongkutklao Hospital

This experimental study compares the effectiveness of Automatic Uterine Massage Machine (AUMM) and Manual Uterine Massage on uterine contraction intensity and the amount of postpartum blood loss within two hours after delivery. The participants consisted of 60 postpartum women who were within 2 hours of their normal delivery at Phramongkutklao Hospital, Bangkok, Thailand. The experimental and comparison groups each consisted of 30 participants allocated by a simple random method when visiting the labour room. The comparison group received a manual uterine massage by a nurse, while the experimental group received AUMM. Both groups received standard postpartum care, which included assessment for postpartum hemorrhage, administration of oxytocin 10 units, and ensuring an empty bladder. Mann-Whitney U test was used to analyze the difference in uterine contraction intensity and amount of postpartum blood loss between the groups. The participants’ characteristics between the groups revealed no statistically significant differences (p &gt; 0.05). The manual uterine massage group exhibited significantly stronger uterine contractions compared to the AUMM group (p &lt; 0.001). The key findings indicated that there was no significant difference in the amount of blood loss during the first 2 hours after delivery between the two groups (p = 0.323). Although using AUMM resulted in a significantly lower uterine contraction intensity, the amount of postpartum blood loss was not significantly different compared to the manual uterine massage group. Therefore, AUMM could be an alternative to manual uterine massage, especially in healthcare facilities facing a shortage of nursing staff, particularly during the critical period of the first 2 hours after delivery.

977: Prostate SBRT with an empty bladder: challenging the dogma

977: Prostate SBRT with an empty bladder: challenging the dogma

Conception and implementation of an MRI-compatible device to elicit the bulbocavernosus reflex for an open spinal cord study.

Functional MRI (fMRI) can be employed to assess neuronal activity in the central nervous system. However, investigating the spinal cord using fMRI poses several technical difficulties. Enhancing the fMRI signal intensity in the spinal cord can improve the visualization and analysis of different neural pathways, particularly those involved in bladder function. The bulbocavernosus reflex (BCR) is an excellent method for evaluating the integrity of the sacral spinal cord. Instead of stimulating the glans penis or clitoris, the BCR can be simulated comfortably by tapping the suprapubic region. In this study, we explain the necessity and development of a device to elicit the simulated BCR (sBCR) via suprapubic tapping while conducting an fMRI scan. The device was successfully tested on a group of 20 healthy individuals. Two stimulation task block protocols were administered (empty vs. full bladder). Each block consisted of 40 s of suprapubic tapping followed by 40 s of rest, and the entire sequence was repeated four times. Our device can reliably and consistently elicit sBCR noninvasively as demonstrated by electromyographic recording of pelvic muscles and anal winking. Participants did note mild to moderate discomfort and urge to void during the full bladder task. Our device demonstrates an efficacious approach to elicit sBCR within an MRI bore to assess sacral spinal cord functional activity without generating any significant motion artifacts. This device can explore the mechanisms and processes controlling urinary, digestive, or sexual function within this region in humans.

Patient-reported outcome measures after radical radiotherapy to localised prostate cancer with empty or full bladder preparation: our experience at Singleton Hospital

Patient-reported outcome measures after radical radiotherapy to localised prostate cancer with empty or full bladder preparation: our experience at Singleton Hospital

Effect of bladder volume and compliance on ultrasonographic measurement of bladder wall thickness in children with neurogenic bladder dysfunction

Spina bifida is the most common cause of neurogenic bladder dysfunction in children. Measurement of bladder wall thickness (BWT) is non-invasive, low-cost, and may be complementary to urodynamics in demonstrating bladder condition. It is still unknown the wall thickness response to volume change in bladders with different compliance states. To determine the most appropriate measurement technique by revealing the differences in measurements performed in different compliance and volume conditions in children with neurogenic bladder. In the prospective study in 2022, patients with spina bifida who continued their urological follow-up in our spina bifida center were included. Patients with a diagnosis of the neurogenic bladder who performed clean intermittent catheterization at least 4-6 times a day and had a recent urodynamic result in the last 6 months were included in the study. According to urodynamic results, patients were divided into two groups normocompliant (NC) and low-compliant (LC) bladders. BWT measurements were made from the anterior, posterior, right lateral, and left lateral walls of the bladder 3 times as full, half-volume, and an empty bladder. The study included 50 patients (NC group n:21, LC group n:29). The mean age of 24 female and 26 male patients was 6.45±4.07 years. In all BWT measurements, a significant increase in wall thickness was observed with decreasing bladder volume. The best correlation between bladder volume and BWT was found in the anterior wall with a weak negative correlation (p=0.049, r=-0.280). However, lateral wall measurements were significantly higher in low compliant patients compared to normocompliant patients when the bladder was full. The mean right lateral wall thickness was 1.58±0.68mm in the NC group and 2.18±1.35mm in the LC group (p=0.044). Left lateral wall thickness was 1.45±0.44mm in the NC group and 2.02±1.4mm in the LC group (p=0.033). Although standardization has been tried to be achieved in BWT measurements, we understand from the studies in the literature that there is no unity in practice. Lateral wall measurements were found to be significantly higher in LC patients compared to normocompliants in full bladder suggesting that more accurate BWT follow-up can be performed with lateral wall measurements in neurogenic bladder patients if bladder compliance is low. The present study seems to be the first study in the literature in which bladder compliance and ultrasonographic bladder wall thickness measurements were evaluated together in children with neurogenic bladder dysfunction.

Early Experience with CBCT-Guided Online Adaptive Radiotherapy for Muscle Invasive Bladder Cancer.

Radiation therapy for muscle-invasive bladder cancer (MIBC) requires substantial planning target volume (PTV) margins to account for variability in bladder filling as well as other anatomic changes. We hypothesized that CBCT-guided online adaptive RT (oART) may both improve target coverage and reduce normal tissue exposure as compared to non-adaptive RT. The purpose of this study is to report the dosimetric results of our initial experience utilizing oART for treatment of MIBC. Seven patients with MIBC were treated with oART over a 1-year period. Patients were simulated with an empty bladder and were asked to void prior to each treatment. Five patients received 55 Gy in 20 fractions to a clinical target volume (CTV) expanded from the TURBT bed and 46 Gy simultaneously to the remaining bladder and for 2 patients the high dose CTV was the entire bladder. PTVs consisted of a 7mm isometric expansion of the CTV. The oART delivery process initially coregisters the daily CBCT to the treatment planning CBCT using skeletal alignment. Target volumes and organs-at-risk (OARs) were modified at each treatment session and the plan re-optimized to meet prespecified clinical goals. Target coverage and OAR dosimetric parameters for the adaptive were compared non-adaptive (scheduled) plan for each fraction using the Wilcoxon paired test of means. The adapted plan was selected for delivery for all fractions across all patients. Daily bladder volumes differed from the bladder volume at simulation by a mean of 60cc ± 66cc. At least 95% of the high dose CTV was covered by the prescription dose for 139 (99.3%) fractions with the oART plan as compared to 70 (50%) fractions with scheduled. A portion of the high dose CTV was outside of the 80% isodose line for 13 (9.3%) of scheduled fractions and was outside of the 50% isodose line for 2 (0.01%) of scheduled fractions. There were no cases of oART plans where any portion of the high dose CTV was outside of the 90% isodose line. A comparison of selected target and OAR dosimetric parameters is shown in the Table. oART treatment plans were associated with greater target coverage and less OAR exposure for all metrics. In this initial experience, oART resulted in acceptable delivered dosimetry to target volumes with a reduced PTV margin of 7mm despite considerable daily variation in bladder volume. As expected, oART plans were associated with improved target coverage and OAR dosimetry. Future patient-centered studies should explore the clinical impact of reduced margin oART for patients with MIBC.

Is the Brainstem Activation Different Between Healthy Young Male and Female Volunteers at Initiation of Voiding? A High Definition 7-Tesla Magnetic Resonance Imaging Study.

Assessing brainstem function in humans through typical neuroimaging modalities has been challenging. Our objective was to evaluate brain and brainstem activation patterns during initiation of voiding in healthy males and females utilizing a 7 Tesla magnetic resonance imaging (MRI) scanner and a noninvasive brain-bladder functional MRI (fMRI) protocol. Twenty healthy adult volunteers (10 males and 10 females) with no history of urinary symptoms were recruited. Each volunteer underwent a clinic uroflow and postvoid residual assessment and was asked to consume water prior to entering the scanner. Anatomical and diffusion tensor images were obtained first, followed by a blood oxygenation level dependent (BOLD) resting-state fMRI (rs-fMRI) during the empty bladder. Subjects indicated when they felt the urge to void, and a full bladder rs-fMRI was obtained. Once completed, the subjects began 5 voiding cycles, where the first 7.5 seconds of each voiding cycle was identified as "initiation of voiding." BOLD activation maps were generated, and regions of interests with a t-value greater than 2.1 were deemed statistically significant. We present 5 distinct regions within the periaqueductal gray (PAG) and pontine micturition center (PMC) with statistically significant activation associated with an initiation of voiding in both men and women, 3 within the PAG and 2 within the PMC. Several additional areas in the brain also demonstrated activation as well. When comparing males to females, there was an overall lower BOLD activation seen in females throughout all regions, with the exception of the caudate lobe. Our study effectively defines regions within the PAG and PMC involved in initiation of voiding in healthy volunteers. To our knowledge, this is the first study investigating differences between male and female brainstem activation utilizing an ultra-high definition 7T MRI.

Robustness Settings for a Plan-of-the-Day IMPT Strategy for Locally Advanced Cervical Cancer

For the treatment of locally advanced cervical cancer (LACC), proton therapy has been proposed as an alternative to photon therapy to mitigate the treatment-induced morbidities. The large anatomic variations in the pelvis presents a challenge in achieving adequate target coverage and therefore plan-of-the-day (PotD) strategies have been proposed. However, appropriate robustness settings for a PotD strategy for LACC IMPT are currently lacking. The aim of this study is to determine these settings by evaluating the dose of simulated treatment courses. This study included thirteen patients treated for LACC. For each patient, a full and empty bladder planning CT scan (pCT) and three to five weekly repeat CT scans (reCTs) were available. ITVs were constructed by interpolating between the cervix-uteri on the pCTs. Depending on the range of motion, a library of 1 to 4 plans was created. Four-beam IMPT plans were created using our in-house automated treatment planning system. For optimization and evaluation, five set-up robustness (SR) settings were considered, namely 2, 3, 4, 5, or 7 mm set-up error. On top of that, a 3% range robustness (RR) was used. The evaluation was done on 28 error scenarios. The prescribed dose to the targets was V42.75 Gy > 95% on the voxelwise-min dose. Ten treatments per patient were simulated by recalculating the dose on the reCTs, with additional simulated treatment uncertainties. Adequate coverage was assumed when at least 90% of the treatments had a target coverage of V42.75 Gy > 95%. This was evaluated on the low-risk CTV (CTV-LR) and elective CTV (CTV-E) by accumulating the dose on the different reCTs. The volume that gets >40 Gy was also quantified for five different OAR. In total, 125 treatment plans were created. With these plans, 130 treatments were simulated on the reCTs. The table shows the percentage of the 130 treatments that reached the dose criterion for the five SR error scenarios. For a SR of 4 mm and larger, the dose criterion is fulfilled for the CTV-E in at least 90% of the treatments. For the CTV-LR, adequate coverage could not be reached for any of the five robustness settings. The table also shows the relative volume receiving >40 Gy for five OAR. All OAR V40 increase linearly with larger SR. Adequate CTV-E coverage with a PotD strategy was reached with modest robust optimization. For the CTV-LR, however, this could not be achieved, not even with an SR of 7 mm. Since the setup is a global parameter and a larger SR would greatly increase the dose for OAR, we advocate the addition of margins around the ITV to address the underdosages.

In Vitro Validation of a Novel Continuous Intra-Abdominal Pressure Measurement System (TraumaGuard).

Introduction: Intra-abdominal pressure (IAP) has been recognized as an important vital sign in critically ill patients. Due to the high prevalence and incidence of intra-abdominal hypertension in surgical (trauma, burns, cardiac) and medical (sepsis, liver cirrhosis, acute kidney injury) patients, continuous IAP (CIAP) monitoring has been proposed. This research was aimed at validating a new CIAP monitoring device, the TraumaGuard from Sentinel Medical Technologies, against the gold standard (height of a water column) in an in vitro setting and performing a comparative analysis among different CIAP measurement technologies (including two intra-gastric and two intra-bladder measurement devices). A technical and clinical guideline addressing the strengths and weaknesses of each device is provided as well. Methods: Five different CIAP measurement devices (two intra-gastric and three intra-vesical), including the former CiMON, Spiegelberg, Serenno, TraumaGuard, and Accuryn, were validated against the gold standard water column pressure in a bench-top abdominal phantom. The impacts of body temperature and bladder fill volume (for the intra-vesical methods) were evaluated for each system. Subsequently, 48 h of continuous monitoring (n = 2880) on top of intermittent IAP (n = 300) readings were captured for each device. Using Pearson's and Lin's correlations, concordance, and Bland and Altman analyses, the accuracy, precision, percentage error, correlation and concordance coefficients, bias, and limits of agreement were calculated for all the different devices. We also performed error grid analysis on the CIAP measurements to provide an overview of the involved risk level due to wrong IAP measurements and calculated the area under the curve and time above a certain IAP threshold. Lastly, the robustness of each system in tracking the dynamic variations of the raw IAP signal due to respirations and heartbeats was evaluated as well. Results: The TraumaGuard was the only technology able to measure the IAP with an empty artificial bladder. No important temperature dependency was observed for the investigated devices except for the Spiegelberg, which displayed higher IAP values when the temperature was increased, but this could be adjusted through recalibration. All the studied devices showed excellent ability for IAP monitoring, although the intra-vesical IAP measurements seem more reliable. In general, the TraumaGuard, Accuryn, and Serenno showed better accuracy compared to intra-gastric measurement devices. On average, biases of +0.71, +0.93, +0.29, +0.25, and -0.06 mm Hg were observed for the CiMON, Spiegelberg, Serenno, TraumaGuard, and Accuryn, respectively. All of the equipment showed percentage errors smaller than 25%. Regarding the correlation and concordance coefficients, the Serenno and TraumaGuard showed the best results (R2 = 0.98, p = 0.001, concordance coefficient of 99.5%). Error grid analysis based on the Abdominal Compartment Society guidelines showed a very low associated risk level of inappropriate treatment strategies due to erroneous IAP measurements. Regarding the dynamic tracings of the raw IAP signal, all the systems can track respiratory variations and derived parameters; however, the CiMON was slightly superior compared to the other technologies. Conclusions: According to the research guidelines of the Abdominal Compartment Society (WSACS), this in vitro study shows that the TraumaGuard can be used interchangeably with the gold standard for measuring continuous IAP, even in an empty artificial bladder. Confirmation studies with the TraumaGuard in animals and humans are warranted to further validate these findings.

Обструкція сечоводу після ендоскопічної корекції міхурово-сечовідного рефлюксу в дітей

Purpose - to investigate the ureteral obstruction (UO) frequency after endoscopic injection of the vesicoureteral reflux (VUR) in children. Materials and methods. 1068 children aged 8 months -15 years were respectively reviewed after endoscopic treatment of the VUR grades 2-4. The following factors were analyzed in terms of ureteral obstruction: age, sex, reflux grade. Also the clinical manifestations were reviewed as the ureteral obstruction management types (conservative - 28 (52.8%), stenting - (26.5%), reimplantation of the ureter - 11 (20.7%) as well. Statistical analysis of the frequency of OS (categorical data) was performed using nonparametric estimation methods (χ², Fisher's exact test). A difference of p&lt;0.05 was considered statistically significant. Results. The total incidence of ureteral obstruction was 3.44% (53/1539 ureters). There were early (41 children) and late (12 children) obstructed units. The following risk factors for developing ureteral obstruction proved to be significant: sex (males), low reflux grade. The early UO was treated mostly with watchful waiting, stenting (13 cases) and 2 cases were submitted to open surgery. In late UO ureteral reimplantation was utilized (9 cases) as well as ureteral stenting was helpful. Conclusions. UO is an infrequent but essential complication of the endoscopic VUR correction. The early UO cases are effectively treated by watchful waiting with/without empty bladder or ureteral stenting. Ureteral reimplantation seems to be the main procedure in late UO cases. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction

Introduction and hypothesisThis manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction.MethodsAn international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed.ResultsThe search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP.ConclusionsThe clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.